Provider Demographics
NPI:1073839643
Name:PAEZ, GUSTAVO ENRIQUE (MA)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:ENRIQUE
Last Name:PAEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 AVE WINSTON CHURCHILL APT 907
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6711
Mailing Address - Country:US
Mailing Address - Phone:787-587-7569
Mailing Address - Fax:
Practice Address - Street 1:60 AVE WINSTON CHURCHILL APT 907
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6711
Practice Address - Country:US
Practice Address - Phone:787-587-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3141103T00000X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist